DME Flashcards
1
Q
What is approach in a ME?
A
ABCDE
Airway
Breathing
Circulation
Disability
Exposure
2
Q
Why do ABCDE approach?
A
- Needed to assess acute illness in pt
- A decision procedure
- Treat as you find
- Cyclical reassessment
- Systematic
- Universal assessment tool
3
Q
What approach would you use if pt is collapsed / unconscious?
A
DRS ABC
Danger
Response
Shout for help
Airway
Breathing
Circulation
4
Q
How do you assess Airway? (3)
A
Initial observations
o Hoarse voice
o Itching / burning / difficulty swallowing
o Chest tightness
o Breathing difficulty
Aural inspection
o Wheeze / stridor / cough / snore / gurgle / shortness of breath / change in voice
Visual inspection
o Irritation around mouth
o Swelling of lips
o Injury e.g. a cut
o Foreign body in the mouth
5
Q
How to assess Breathing? (3)
A
- Pulse oximetry
- Respiration rate
- Peak expiratory flow
6
Q
How to do pulse oximetry / what does it record? What can it be affected by?
A
Records:
- Pulse, in beats per minute
- Blood oxygen saturation, %
Reading can be affected by cold hands / movement / nail varnish
7
Q
How to record respiration rate?
What is normal respiration rate (adult)?
A
Count rise and fall of pt chest for 30 seconds
Multiply by 2
Normal adult respiration rate: 12 – 20 breaths per minute
- Low when sleeping / high physical fitness
- High when exercising / emotional stress
8
Q
How to measure peak expiratory flow?
A
- Select correct size, smaller one for petite adults / children
- Push pointer to zero
- Pt standing or sitting upright
- Pt should take deep breath in and blow as hard / fast as possible into the meter
- Lips should be sealed around mouthpiece
- Should be held horizontally
- Record reading 3 x
- Compare highest reading to pt best value in 2 years / against standard population values
9
Q
How do you assess Circulation? (4)
A
- Reported symptoms
- Heart rate and rhythm
- Capillary refill times
- Blood pressure
10
Q
Which reported symptoms should you ask about to assess Circulation?
A
- Palpitations / chest pain - May indicate cardiac arrythmia / cardiac ischaemia / panic attack
- Coldness / tingling of peripheries
- Visual / auditory disturbance, dizziness, feeling faint / nausea
11
Q
What is normal adult pulse rate?
A
60 - 100 bpm
12
Q
How do you assess heart rate and rhythm?
A
Palpate radial pulse
- Place fingers on wrist
- Count beats in 30s then x2
13
Q
When may you not be able to detect radial pulse? What should you do instead?
A
- Pt with low BP
- Palpate carotid pulse - place finger between trachea and sternocleidomastoid muscle - count beats in 30s then x2
14
Q
When should you use capillary refill time? How to measure? What is normal CRT?
A
- Crude measure when BP monitoring unavailable
- Hold pt hand, pinch fingerer 5s see how long takes to return to normal colour
< 2s
15
Q
How to measure BP?
A
- Ask pt to roll up sleeves
- Place cuff above elbow joint directly on skin
- Align with brachial artery mark
- Secure cuff, explain to pt may feel tight while it inflates
- Press start and record readings
16
Q
Difference between systolic and diastolic BP?
A
- Systolic measures force in heart contraction
- Diastolic measures heart in relaxation
17
Q
What is considered high and low systolic BP?
A
< 90 mmHg = critically low
91 – 100 mmHg = very low
101 – 110 mmHg = low
111 – 219mmHg = normal
> 220 mmHg = high
18
Q
How to assess Disability? (3)
A
- Capillary blood glucose
- AVPU
- Pain assessment
19
Q
What is normal adult capillary blood glucose?
A
4 - 8 mmol / L
20
Q
How to measure capillary blood glucose?
A
Insert test strip into glucometer
Obtain a pinprick blood sample from pt finger
Dispose of sharps
Apply blood droplet to test strip
Dispose appropriately
Record reading
21
Q
What is AVPU?
A
Neurological assessment
Alert
Verbal - loud voice
Verbal - shouting
Pain - touch
Pain - shake
Pain - earlobe pinch
Unresponsive
22
Q
How to carry out pain assessment?
A
SOCRATES
Site
Onset
Character
Radiating
Time
Exacerbating factors
Severity
23
Q
How to assess exposure?
A
Visual inspection
- Should finalise assessment
- Needs pt consent
24
Q
What is acute cardiac ischaemia essentially?
A
Reduced o2 flow to the heart
25
What are 2 causes of ACI?
1. Stable angina
2. Acute coronary syndrome ACS
26
What is stable angina?
Chronic condition caused by narrow coronary arteries
27
What 2 things does ACS describe?
1. Myocardial infarction MI
2. Unstable angina
More severe interruption of blood flow to the heart
28
What is unstable angina?
Deterioration without damage to heart muscle - chronic condition
29
Difference between ST and non ST elevation MI?
ST elevation MI - damage to heart muscle great enough to be seen in ST segment on ECG
30
How does stable angina differ at rest / in exertion?
At rest = normal blood flow, atheroma plaque on vessel wall reduces lumen size but still sufficient to meet O2 demand
Exertion / heightened emotion = increased O2 demand, lumen size not insufficient and symptoms of ischaemia
31
How does ACS differ at rest / in exertion?
At rest = larger atheroma plaque present – blood flow reduced – ischaemia without exertion / emotional triggers
Exertion = ischaemia symptoms greater
32
How does a clot form?
Atheroma creates narrow lumen which increases BP – pressure erodes atheroma plaque – causes bleeding and blood clot forms – occludes vessel more
33
Risk factors for ACS?
Diabetes
Hypertension
Obesity
Smoking
34
How does ACS present?
- Chest pain
- Radiation to arm, back, jaw
- Shortness of breath
- Nausea
- Abdominal pain
- Fatigue
Not all pts report chest pain (women, elderly, diabetics)
35
How can you differentiate between stable angina and ACS? Approaches?
ABCDE
THE DRS
36
What does THE DRS stand for?
Trigger
History
Episodes
Duration
Resolution
Severity
37
Use THE DRS to compare ACS with stable angina
Trigger - ACS unclear, SA obvious e.g. exertion/emotion
History - ACS none, SA known history chest pain
Episodes - ACS increased freq, SA no change in episode freq
Duration - ACS symptoms >15mins, SA resolves <15mins
Resolution - ACS slow response to GTN, SA may resolve with rest and fast response to GTN <4 activations
Severity - ACS worse than typical angina pain, SA typical pain
38
How to manage stable angina? (3)
- Rest
- GTN spray
- Monitor and review ABCDE
39
How should you deliver GTN spray? Dosage?
Do not shake bottle - activate pump
Under tongue
1-2 sprays every 5 mins
Max 6 doses
If symptoms persist after 4 doses / longer than 15 mins call 999
40
How to manage ACS? (4)
- GTN spray
- Aspirin - single chewable tablet 300mg
- o2
- Monitor, review ABCDE
41
When should you use o2 to manage ACS?
Hypoxic pt
o2 sat <94%
Simple face mask 5-10 L/min
If high risk hypercapnia nasal cannula 4 L/min
If history COPD nasal cannula 1-2 L/min
42
What causes anaphylaxis?
Over release of histamines
Affects, airway, breathing and circulation
Life threatening hypersensitivity
43
Common alleges causing anaphylactic rxn?
Foods - nuts / eggs / shellfish
Insect stings - bees / wasps
Medication - Penicillin / NSAIDs
Materials - latex
44
Anaphylaxis - how is airway affected?
Visually - soft tissues swell e.g. tongue, soft palate
Auditory - stridor / wheeze / change of voice / coughing
C/O - itching / difficulty swallowing
45
Anaphylaxis - how is breathing affected?
- High respiratory rate
- Low o2 saturation <94%
- Pt experience shortness of breath, runny nose, cough
46
What is normal adult o2 saturation - for low and high risk hypercapnia?
Low risk 94 - 98% o2 sat
High risk 88 - 92% o2 sat
47
When should you use PEF to assess breathing?
If you suspect asthma
48
Who should GTN not be given to?
Pts:
- Allergic to nitrate meds
- Hypotensive
- Mitral stenosis
- Pregnant
- On Viagra
49
Anaphylaxis - how is circulation affected?
- High HR
- Low BP
- Pt experiences dizziness, visual disturbances, pale skin
50
Anaphylaxis - how is disability affected?
- Reduced consciousness
- Fatigue / confusion
- Anxiety
51
Anaphylaxis - how is exposure affected?
- Rash / flushed skin
- Cyanosis - blueish skin
- Angiodema - swellings
- Cold peripheries / itching / sweat
52
How to manage anaphylaxis? (6)
- Call 999
- Remove trigger if possible
- Semi recline pt and elevate legs
- Give IM adrenaline
- Give o2
- Salbutamol
53
Dosages of IM adrenaline
<6 months
<6 years
6 - 12
Adult and child > 12 years
<6 months 100 - 150mg
<6 years 150mg
6 - 12 years 300mg
Adult and child > 12 years 500mg
54
What are different types of IM adrenaline?
- Epi Pen
- Ampoules
55
How much o2 would you give in anaphylaxis? What type of face mask?
15 L/min via non-rebreather mask
56
How would you give Salbutamol in anaphylaxis? What dosage?
Adapted technique using air spacer
2 puffs every 2 minutes
(Total of 10 over 10-20 minutes)
57
What does the adapted technique involve?
- Remove caps from spacer and inhaler
- Shake inhaler
- Insert mouthpiece into spacer
- Ask pt to exhale
- Apply face mask, ensure effective seal
- Give 1 puff, ask pt to inhale
- Ask pt to hold breath for 10s
58
How would you prep for giving O2 for anaphylaxis?
- Place finger over non rebreather mask valve
- O2 should pump bag
- Place mask over pt nose and mouth
- Effective seal
- Monitor O2 sats
59
If not anaphylaxis - what other similar ME could it be? (3)
Asthma
ACI
Hyperventilation
60
Define asthma
Long term respiratory condition
Chronic bronchial inflammation, increased mucus production and tissue oedema
61
What are the 3 types of asthma?
- Moderate
- Acute severe
- Life threatening
62
How does asthma present?
Wheezing
Coughing
Breathlessness
63
What should all suspected asthma pts be assumed to be prior to assessment?
Acute severe
64
Airway - asthma?
Audible wheezing
65
Breathing - asthma?
Increased respiratory rate
Reduced PEF
O2 sats <94%
66
Circulation - asthma?
High HR
Arrhythmia - life threatening
67
Disability - asthma?
Anxiety
Deteriorating conscious level - sometimes
68
Exposure - asthma?
Cyanosis
69
Difference in respiratory rate for mod / acute sev / life threat?
Mod - less than 25bpm
Acute sev - 25bpm +
Life threatening - 25bpm +
70
Difference in HR for mod / acute sev / life threat?
Mod - less than 110bpm
Acute sev - 110bpm +
Life threatening - Arrhythmia
71
Difference in O2 sats for mod / acute sev / life threat?
Mod - more than 92%
Acute sev - more than 92%
Life threatening - less than 92%
72
Difference in PEF for mod / acute sev / life threat?
Mod - between 50-70%
Acute sev - between 33-50%
Life threatening - less than 33%
73
Other differences between mod / acute sev / life threatening asthma?
Mod - speech normal
Acute sev - unable to complete full sentences
Life threatening - altered consciousness, cyanosis, poor respiratory effort
74
When should you call 999 for asthma?
What should lower threshold to call 999?
- Acute sev / life threatening on assessment
- No improvement / worsening with tx
- If 6 activations Salbutamol ineffective
- Prev near-fatal asthma
- Hospital admission for asthma in last 12 months
75
How is asthma managed?
Salbutamol with spacer
O2 with simple face mask
76
Dosage of salbutamol for asthma?
2 puffs every 2 minutes (total 10 in 10-20mins)
Mod - 2 immediately
Acute sev - 4 immediately
Life threatening - 6 immediately
77
At what O2 sats do we start giving O2?
<94%
78
What dose of O2 for asthma?
5-10 L/min via simple face mask
If pt COPD 1-2 L/min
79
How do you record PEF?
- Push bar back to zero
- Sit pt up
- Pt to make forced exhale
- Record 3 best results
- Compare best to pt norm
80
If not asthma what other ME could it be?
Anaphylaxis
Acute cardiac ischaemia
Hyperventilation
81
Which pts are low risk hypercapnia? Management?
Less than 94% O2 sats
Administer O2 5-10 L/min via simple face mask
82
Which pts are high risk hypercapnia? Management?
Less than 88% O2 sats
Administer O2 1-2 L/min via nasal cannula
83
When should you call 999 for asthma ME?
If pt acute severe / life threatening asthma
If 6 activations of salbutamol ineffective
84
What is hyperventilation?
Stress response - psychological
85
Airway - hyperventilation
Noisy breathing
86
Breathing - hyperventilation
Increased respiratory rate / effort
Normal O2 sats
87
What is a normal breathing rate range?
12 - 20 breaths per min
88
What is normal heart rate range?
60 - 100 beats per min
89
What is normal blood glucose range?
4 - 8 mmol/Hg
90
Circulation - hyperventilation
High HR
Palpitations
91
Disability - hyperventilation
Anxiety
Chest pain
92
Exposure - hyperventilation
Blotchy rash
Muscle stiffness / spasm
93
What 3As should be ruled out to identify tx as hyperventilation?
Asthma
ACI
Anaphylaxis
94
How should hyperventilation be managed?
- Remove stressor
- Calm environment
- Coach slow breathing
- Reassess with ABCDE
- Monitor then safe discharge
95
What should you do if pt remains same / deteriorates after hyperventilation tx?
Reconsider 3As
Call 999
96
What are breathing techniques you can coach pt through?
- Through pursed lips
- Offer water to naturally slow breathing
- Abdominal breathing
- Breathing through one nostril, alternating
97
Which pts are at risk of hypoglycaemia?
Type 1 DM
Type 2 DM diet controlled
Type 2 DM insulin
98
How is severity of hypoglycaemia assessed?
Behaviour and AVPU
99
Use AVPU to give hypoglycaemia severity
- Alert = conscious, can self help and swallow - MILD
- Verbal = responds to voice, conscious but drowsy - MODERATE
- Pain = responds to touch, unable to self help - MODERATE
- Pain = responds to shaking, fitting / aggressive - SEVERE
- Unresponsive = unconscious - SEVERE
100
What are symptoms of hypoglycaemia?
Shaking
Sweating
Palpitations
Confusion
Aggression
Slurred speech
Loss of consciousness
101
How to manage mild hypoglycaemia?
Quick acting carb and long acting carb
Glucose liquid and then biscuits
102
How to manage moderate hypoglycaemia?
Quick acting carb
2 tubes glucose gel
103
How to manage severe hypoglycaemia?
1mg glucagon, intramuscular / sub cut / intravenous
Call 999
104
What determines hypoglycaemia?
CBG > 4mmol/L
105
When should you repeat CBG?
After 15 mins and recategorise severity
106
What should you do if following reassessment CBG less than 4?
- Fast acting carb (glucose gel / liquid) max 3x
- Until CBG more than 4
- Then give complex carb (biscuits)
- If CBG stays less than 4 after 3 fast acting carbs call 999
107
What should you do if following reassessment CBG more than 4?
- Give complex carb (biscuits)
- Monitor until 2 CBGs recorded more than 4
- Safe discharge
108
When is glucose juice / tablets indicated?
Fast acting for mild hypoglycaemia - first line
109
When is glucose gel indicated?
Fast acting for moderate hypoglycaemia - first line
110
Which is best way to give glucagon injection according to NICE Guidelines?
Intramuscular
111
How is glucagon hypo kit used?
- Check allergies, dose and expiry date then open
- Use pre filled syringe and inject 1.1ml water into vial
- Shake until white powder is dissolved
- Draw solution back into syringe
112
How can you identify a seizure?
Loss of consciousness
Erratic muscular movement
Grunting noises
113
How should you manage seizure in tonic phase?
Lay pt flat
Remove items e.g. phone, keys
Protect pts head
Note time
114
How should you manage seizure in clonic phase?
15 L O2 non rebreather mask
Watch pt entire time
115
How should you manage seizure in post-ictal phase?
Pt in recovery position
Remove O2 once start to come round
Perform ABCDE assessment
116
What should you do if seizure is less than 5 mins and no injury is sustained?
Support and monitor the pt
Assess ABCDE and check CBG
117
What should you do if seizure is more than 5 mins and pt has history of seizures?
Follow care plan
Or call 999
Then reassess ABCDE and check CBG
118
What 3 occasions should you always call 999 if pt has had a seizure?
- First ever seizure
- Seizure recurs 3 times in an hour
- Seizure less than 5 mins but pt known to have prolonged seizures
119
How long do most tonic-clonic seizures last?
2 - 3 mins
120
What is syncope?
Rapid loss of consciousness
121
What are the red flags you should look out for? (7)
More than 4 mins
Poor recovery, remains drowsy
No warning signs
Recurring when upright again
Significant cardiac history
Cardiac symptoms - chest pain, palpitations
Syncope from supine
122
How would you describe most syncope episodes in dental settings?
Benign
- Postural hypotension
- Vasovagal
123
When should you call 999 for syncope?
Red flag identified
Injury sustained beyond first aid
124
How should you manage syncope immediately?
Lay flat, elevate legs
Identify red flags and injuries
125
How should you manage syncope if no red flags or injuries?
Move pt from flat into seated pt
Reassess
Monitor, safe discharge
126
How can you elevate legs following syncope?
Curls legs into body
Legs on a chair
127
When should you use non rebreather mask?
Anaphylaxis and seizure
128
What O2 flow rate for non rebreather mask?
15 L/min
129
When should you use nasal cannula?
High risk hypercapnia - O2 less than 88%
130
What O2 flow rate for nasal cannula?
1 - 2 L/min
131
When should you use a simple face mask?
O2 sats less than 94% hypoxic but low risk hypercapnia
132
What O2 flow rate for simple face mask?
5 - 10 L/min
133
If pt on simple face mask O2 sats drop below 85% how should you manage?
Give 15 L/min with non rebreather mask
